Inspection·September 11, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm During an interview on 09/11/2024 at 11:16 a.m. with Staff BB, License Practical Nurse/Unit Manger (LPN/ Unit Manager), she stated Resident #7 was a dependent resident with limited mobility and could not walk. Therapy was working with her by providing her with bed exercise. She did not have upper extremity control. She said she had not seen the Resident #7 out the bed. The resident did not have access to a wheelchair because she needed a reclining wheelchair. Residents Affected - Few During an interview on 09/11/2024 at 1:00 p.m. with the Rehab Director, she stated Resident #7 was picked up today, 09/11/2024, for therapy services. She was referred to therapy by nursing. The therapy process was that they screened all residents admitted to the facility for a mobility device. She could not answer why Resident #7 did not have a wheelchair but said they would address the issues so the resident had a wheelchair moving forward. Review of a policy titled, Standards and Guidelines: ADL Care and Services Revised dated 1/2024 showed Standards: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Gudelines: Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Procedure: 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) are met. 4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care. Including appropriate support and assistance with: b. Mobility ( Transfer and ambulation, including walking). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 2 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and record review, the facility failed to provide two (#76 and #82) of forty-six sampled residents with privacy during two of four days observed. Residents Affected - Few Findings included: 1. On 9/8/2024 at 10:00 a.m., the 100 hall was toured and observed. The 100/200 hall was a very high trafficked hall where staff, residents and visitors pass through. The hall was busy with housekeeping staff, direct care staff, residents ambulating/self propelling, nurses and other departmental staff. Upon reaching Resident #76's room, it was observed her room door was all the way open and she was noted lying flat in bed, on top of the bed linen and with her head over bed approximately twenty-five degrees. Further observations revealed she was wearing a hospital gown. Resident #76's hospital gown was observed pulled up all the way to her waste and she was observed totally nude. There did not appear to be any clothing on the floor, bed, nor was there any evidence of any pull up briefs at or around the bed. Resident #76 resided in the (door) bed and both the door and the privacy curtain were opened all the way. Further observations revealed a male resident seated in a wheelchair, just across from Resident #76's door and was facing her. The resident was not interviewable, but he was positioned in such a way where he could see Resident #76. Also, various staff were observed walking by the Resident's room and none stopped to either close the door or assist her with re gowning or dressing. Resident #76 was observed from the hallway totally naked from the waste down from at least 10:00 a.m. through to 10:11 a.m. with no staff intervention. On 9/8/2024 at 10:12 a.m., Resident #76's room was again approached. She moved in bed in such a manner that when she turned and the gown dropped down and covered her genitals. The resident could not respond with specific answers. She was asked if she needed or wanted any privacy and she did not answer. She was asked if staff provide her privacy when in need and she did not answer. On 9/9/2024 at 8:30 a.m., Resident #76 was again noted in her room and lying upright in bed and lying on top of the bed linen. She was observed wearing a hospital gown and the gown was pulled up to her waste. Further observations revealed she was wearing an adult brief and could be observed from the hallway. The room door and the privacy curtain were both opened all the way. The resident was asked about her day and if she needed any staff to help her. She started to sing aloud in phrases that were not understandable. The hallway was observed with high traffic from staff and visitors as the resident could be seen unrobed from the hallway. The resident was observed from the hallway in this position from 8:30 a.m. through to 8:42 a.m. with no staff intervention. An unidentified staff member walked by the resident's room and went inside to pull the resident's gown down, so she was no longer exposed. On 9/11/2024 an interview with the Resident's assigned Certified Nursing Assistant (CNA) Staff H revealed Resident #76 had cognitive impairment and though she could answer some yes and no questions, she was not able to speak to her care and services. Staff H revealed if the resident was found or seen disrobed, staff should immediately provide her with privacy by either assisting to redress, or close the door so people passing the room could not see her. Staff H revealed the resident was usually assisted with dressing right at the beginning of 7-3 shift, or she might be assisted with dressing from staff on the previous shift. Review of Resident #76's medical record, diagnosis sheet, showed she had diagnoses to include but not limited to: Cerebral Infarction, Dementia, Epilepsy, Major Depression, Schizophrenia, and Heart (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 3 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 Failure. Level of Harm - Minimal harm or potential for actual harm Review of the medical record to include nurse progress notes dated 6/25/2024 a. 6/26/2024 15:59 Summary skilled - Resident alert and confused. Residents Affected - Few Review of the nurse progress notes dated from 6/25/2024 through to 9/11/2024 did not have any documented evidence of Resident #76 disrobing or having a history of disrobing. Review of the current care plans with next review date 12/4/2024 revealed the following: 1. Risk for decreased safety and independence related to cognitive communication deficit secondary to CVA, with interventions in place 2. History of exhibiting the following behaviors: Chronic/frequent refusals of care and or services, Non compliant with medications. Can be physically aggressive to staff, refuses, weight at times, with interventions in place. Note: This care plan problem area did not indicate resident has a history of removing adult briefs. 3. Resident has impaired cognitive function/impaired thought process r/t diagnosis of dementia, disease process, with interventions in place 2. On 9/9/2024 at 6:50 a.m., Resident #82 was observed seated in her wheelchair at the nurses station. She was noted dressed for the day and well groomed. She had a blanket over her lap, legs, and pulled up to her neckline. She was pleasant to speak with and had a staff member next to her and was chatting with her. On 9/9/2024 at 7:11 a.m., Resident #82 was observed seated in her wheelchair positioned in the doorway halfway in her room and halfway in the hallway. All of a sudden the resident pulled up her top and removed it all the way by pulling it up and off her head. Resident #82 was completely nude from her waste up and could be seen by all staff and visitors that walked by this area. Residents entire chest was bare and exposed. Further observations in the room revealed a Personal Care Attendant (PCA) Staff C talking with Resident #82's roommate. Staff C was observed to see Resident #82 removing her shirt and she did not say anything to her at first. At 7:14 a.m.,' Staff C called out the resident's name and said; you need to put your shirt on. However, Resident #82 did not attempt to redress. At 7:16 a.m. instead of assisting Resident #82 back in the room and closing the door, she stood at the doorway and put Resident #82's shirt back on. During the time of 7:11 a.m. and 7:16 a.m. over ten various staff and residents had passed by the area when Resident #82 was exposed. Review of Resident #82's medical record, diagnosis sheet, revealed she was admitted to the facility with diagnoses to include but not limited to: Dementia, Major Depression, Anxiety, Insomnia. Review of the current Minimum Data Set (MDS) admission assessment, dated 6/12/2024 revealed a Cognition/Brief Interview Mental Status or BIMS score 9 of 15 which indicated moderately impaired cognition ; Behavior - documented as none exhibited; Mood - None documented as exhibited Review of the nurse progress notes dated from 6/5/2024 through to 9/11/2024 did not show any documentation to support Resident #82 had a history of removing articles of clothing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 4 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 9/10/2024 at 12:20 p.m. an interview with Resident #82's responsible party, confirmed the resident had never exhibited behaviors of removing her clothing. She would hope that staff would respond quickly to redress her if that happened. On 9/11/2024 at 9:35 a.m. an interview with the 100/200 Unit Manager Staff G revealed she did hall rounds throughout the day and if she were to see a resident nude, disrobed or unclothed, she would respond immediately and provide the resident his/her privacy by pulling closed the privacy curtain, closing the door, and attempt to redress the resident. Staff G confirmed this should be an expectation from all staff in the building. Staff G revealed she knew of both Resident #76 and #82 and neither had a history of behaviors of taking off their clothes and disrobing. She revealed she would need to speak with the assigned care aides to see if this was that happened frequently. On 9/11/2024 at 12:10 p.m., the Nursing Home Administrator revealed they did not have a specific Privacy policy and procedure, but had a Resident Rights policy they follow related to resident privacy. The policy provided revealed; Resident Rights, with a last revision date of 1/2024. The policy stated; A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents. The guideline section of the policy revealed; Employees shall treat all residents with kindness, respect and dignity. The procedure section of the policy revealed; 1. Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. A dignified existence; b. Be treated with respect, kindness, and dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 5 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, the facility failed to ensure two of two community shower rooms were cleaned and maintained. Residents Affected - Some Findings included: On 09/08/2024 at 8:55 a.m. an observation was made of the community shower room at the end of the hall between the 100-200 rooms hallway. Entry into the shower room revealed the door to the shower room was not locked. Upon entry into the shower room an observation was made of spots of a brown substance on the floor in front of the sink vanity. Observation was made of spots of the same brown substance in the middle of the floor of the shower room and in the doorway which led into the stall with the toilet. A yellow dirty linen bin was observed inside of the shower room to the left of the door. The lid to the dirty linen bin was on the floor beside the bin. In the stall with the toilet a cabinet was observed on the wall and inside of the cabinet was a spray bottle with a label indicating it was a bottle filled with a cleaning solution. The cabinet had a lock on it, but the cabinet was not locked and a key for the cabinet was not observed. Two shower chairs were observed inside one of the three shower stalls. One of the shower chairs was observed to have a comb with hair in it laying on top of the chair seat. On the same chair there was a yellowish-brown substance on top of the chair seat to the right of the opening in the chair. Another shower chair was observed with a brown substance on top of the seat of the chair towards the back right side of the opening of the chair. An observation was made of the drain in one of the shower stalls showing hair in the drain and gauze with two pieces of tape attached. (Photographic Evidence Obtained) On 09/09/2024 at 8:20 a.m. an observation was made of the community shower room at the end of the hall between the 100-200 rooms hallway. Upon entry into the shower room an observation was made of spots of a brown substance in the middle of the floor of the shower room. An observation was made of the drain in one of the shower stalls showing hair in the drain. A shower chair was observed with a brown substance on top of the seat of the chair towards the back right side of the opening of the chair. An observation was made underneath the mat on top of the shower bed revealing spots of a reddish-brown substance on the mesh. (Photographic Evidence Obtained) On 09/09/2024 at 8:35 a.m. an observation was made of the community shower room located on the 400 rooms hallway. An observation was made underneath the mat on top of the shower bed revealing spots of a thick, odoriferous, brown-black substance on the mesh. (Photographic Evidence Obtained) During an interview on 09/10/2024 at 10:12 a.m. with Staff P, Housekeeper, she said the Certified Nursing Assistants (CNA) were supposed to clean up the shower area after they gave resident showers. Housekeeping was responsible for cleaning floors, disinfecting, and cleaning the shower area on their usual cleaning rounds. The CNA's were responsible for cleaning in between routine housekeeping cleanings. An interview was conducted with Staff M, Housekeeping Supervisor and Staff N, Environmental Services Director on 09/10/2024 at 12:06 p.m. Staff M said the housekeeping responsibilities of the shower rooms included disinfecting, general clean-up, spraying down the showers/walls/doors/handles/mirrors and vanities with the disinfectant and wiping the areas down. Staff M said the CNA's were responsible for disinfecting the entire shower room and the equipment after each resident shower. A spray disinfectant was supposed to be located in a locked cabinet in the toilet stall in each shower room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 6 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Staff N said housekeepers and the floor technicians deep cleaned all shower room equipment weekly which included pressure washing. The equipment should be cleaned and disinfected everyday by housekeeping. Staff N said the facility has four housekeepers working in the facility every day, including weekends, from 7:00 a.m. until 3:00 p.m. One of the four housekeepers worked from 8:00 a.m. until 4:30 p.m. Staff N said if the shower rooms got really dirty and the CNA's were really busy, staff could request housekeeping to return to the shower room to clean it again. Staff N said he was not aware the cabinet in the shower room on the 100-200 hall was not locked and did not have a key attached to it. Review of the policy titled Standards and Guidelines: Shower Room issued 10/2018 and revised 01/2024 showed: The facility will ensure that the shower rooms are cleaned and regularly maintained for the safe environment for residents and staff. The implementation portion of the policy included the following: 2. Remove Debris and Waste: Clear the shower room of any visible debris such as hair, soap scum and personal items. Empty trash bins and replace liners. Remove used towels, washcloths and bath mats for laundering. 3. Surface Cleaning: Shower Walls and Floors: Use a disinfectant cleaner to wipe down the shower walls, floor, and any seating areas. 5. Mopping the Floor: Sweep the floor to remove any loose dirt or debris. Mop the floor with a disinfectant solution, starting from the farthest point in the room and moving towards the door. 7. Inspection: Inspect the shower room for cleanliness. Report any issues to maintenance through the electronic maintenance request system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 7 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure timely and accurate Pre-admission Screening and Resident Review (PASRR) for one (#73) of 23 sampled residents. Residents Affected - Few Findings Included: 2. Review of the admission Record for Resident #73 showed the resident was initially admitted to the facility on [DATE] with a re-entry admission date of 03/04/2024. Admitting diagnoses included schizoaffective disorder bipolar type, major depressive disorder, dementia, mood disorder due to known physiological condition with depressive features. Review of Level I PASRR for Resident #73 dated 03/16/2022, revealed an incomplete PASRR with the qualifying diagnoses of depression, mood disorder and dementia not indicated. During an interview on 09/11/2024 at 9:45 a.m. with Staff S, Registered Nurse (RN) Minimum Data Set (MDS) Director, she said the facility's process for identifying a resident with a possible MD, ID or related condition prior to admission to the facility would start with the Admissions Department. Admissions got the referrals and the referral for the possible resident admission was given to either the Director of Nursing (DON) or Assistant Director of Nursing (ADON) to look at the clinicals to see if there were any reasons to deny the admission. Based on the clinicals, they gave a decision to admit the resident or not. She said the facility identified residents with newly evident or possible serious MD, ID or a related condition after admission to the facility usually after identifying behaviors. If a behavior was identified a psychiatric consult was done and the resident was seen by psychiatric services within seven days. If any new diagnoses were indicated psychiatric services would add them into the electronic medical record. She said when she was made aware of the new diagnoses, she would update the PASRR at that point. She said she also updated the admission PASRR if it was incorrect. She was responsible for making the referral to the appropriate state-designated authority when a resident was identified as having an evident or possible MD, ID or related condition. She said it would automatically trigger the PASRR so she would do that as well. Upon viewing the PASRR for Resident #73, she agreed it was not correct and missing qualifying diagnoses. The facility has no PASRR policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 8 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. An interview was conducted on 09/08/2024 at 09:50 a.m. with Resident #44, she was observed to be in bed, with a hospital gown on, hair was disheveled and unkempt. Resident #44 said she did not know when the last time she got a shower was, but she wanted a shower to wash her hands. Her fingernails were observed to extend past her fingertips with a dark brown, black substances under her bilateral nails. The resident said she had not had her fingernails cut and she did not like them long. Her right hand was observed to be curled into her palm and the resident pulled her fingers out and there was a red indented mark on her palm where her nail was resting in her palm. On 09/09/2024 at 10:01 a.m., Resident #44 was observed to be in her bed, hair disheveled, her bilateral fingernails were observed to extended past her fingertips. On 09/10/2024 at 9:45 a.m., Resident #44 was observed to be in her bed, hair combed. Her bilateral fingernails were observed to be extended past her fingertips. On 09/10/2024 at 5:08 p.m., the Director of Nursing (DON) observed Resident #44 eating her dinner in the dining room. The DON verified Resident #44 had long nails. The DON agreed it was a pattern of fingernails not being trimmed. The DON stated the resident's nails should be observed during care by the aide and reported to the nurse. The aide or the activities person would do the resident's nails. The DON stated if we had someone on light duty, they would do nails also. The DON stated if a resident was a diabetic, the podiatrist would do their toenails. Resident #44 was observed to have food all over the front of her clothes. She was not being assisted by any staff members at the time, even though staff members were observed in the dining room. Resident #44 did not have a clothes protector on. The DON stated that the aides were to fill out shower sheets when they gave residents a shower. The shower sheet was to be reviewed by the nurse if the resident refused, the nurse was to go speak with the resident to encourage a shower. If the resident still refused, the nurse was to document. A review of the admission record for Resident #44 showed the diagnoses included but were not limited to dementia, senile degeneration of the brain, convulsions, recurrent depressive disorder, anxiety, sarcopenia, hydronephrosis, chronic pain, overactive bladder, cancer of the brain, and a history of falling. Review of the quarterly Minimum Data Set, dated [DATE] showed a Brief Mental Interview Status (BIMS) score of 07 which indicated severe impairment. Section GG Functional Abilities and Goals showed the resident required supervision or touching assistance for eating, substantial/maximal assistance for bathing, showering, and personal hygiene. Review of the care plans showed Resident #44 had an ADL (activities of daily living) self-care deficit related to chronic medical conditions, dementia, ADL needs and participation varies revised on 09/09/2024. Interventions included but were not limited to the resident may need dependent assistance of 1 or 2 for ADL care as of 09/09/2024. This may fluctuate with weakness, fatigue, and weight bearing status. The resident needed limited to extensive assistance of 1-2 based on fatigue, weightbearing, weakness as of 05/23/2024. The resident needed supervision, verbal cues and / or touching/steadying of hands to bring food and/or liquid to the mouth and swallow food and / or liquid once the meal is placed before the resident as of 05/23/2024. Encourage and assist with all ADL tasks as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 9 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, personal/oral hygiene, etc. as of 04/29/2024. Review of the type of bathing provided to Resident #44 showed no showers from 08/13/2024 to 09/10/2024. Residents Affected - Few Full bed baths were provided on 08/13/2024, 08/16/2024, 08/20/2024, 08/23/2024, 08/30/2024, 09/03/2024, 09/06/2024, 09/10/2024. A sponge bath was provided on 08/27/2024. Review of the Skin Monitoring: Comprehensive CNA Shower Review (shower sheets) showed to perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin to charge nurse immediately. Forward any problems to the DON for a review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number. The sheets showed the following: 08/13/2024, skin clear, does not need toenails cut, no signature by nursing 08/16/2024, refused shower, skin clear, does not need toenails cut, no signature by nursing 08/20/2024, skin clear, needs toenails cut, no signature by nursing 08/23/2024, refused shower, does not need toenails cut, no signature by nursing 08/27/2024, skin clear, needs toenails cut, no signature by nursing 08/30/2024, skin clear, needs toenails cut, no signature by nursing 09/03/2024, refused shower, does not need toenails cut, no signature by nursing 09/06/2024, full bed bath, does not need toenails cut, no signature by nursing During an interview on 09/11/2024 at 10:33 a.m. the DON reviewed the Skin Monitoring: Comprehensive CNA Shower Review sheets. The DON verified they showed the resident had refused showers on 08/16/2024, 08/23/2024 and 09/03/2024 and a full bed bath on 09/06/2024. The DON verified that the 08/20/2024, 8/27/2024, 08/30/2024 notes showed the resident needed her toenails cut. The DON stated the need for toenails to be cut would be subjective to the individual giving the bath. If the resident was diabetic, the aide was not expected to cut the toenails. The DON stated the nurse was to sign off on the shower sheet if the resident refused to take a shower. The DON verified the resident refused to shower based on documentation on 08/16/2024, 08/23/2024, 09/03/2024 and the nurse had not signed off on the shower sheet as had reviewed. The DON stated the aide should have taken the shower sheet to the nurse for review. The DON stated the aides needed more education. The DON stated that Resident #44 should have been offered a clothing protector during dining. The DON stated that she was in the dining room for more assistance, as needed. The DON reviewed the care plans and stated that the ADL care plan showed Resident #44 was to have supervision and cuing assistance for eating. The DON stated the ADL care plan showed to provide choice for care provisions, shower twice a week. The DON stated the care plan showed the resident was resistive to care, non-compliant with showers (which was added on 09/11/2024 during survey). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 10 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. An observation was conducted on 09/08/2024 at 09:31 a.m. Resident #51 was observed in bed. She was observed to have a flowered shirt on and she said she had been wearing the shirt for three days. She was also observed to have bilateral fingernails which extended past her fingertips with a black substance under them. An observation was conducted on 09/09/2024 at 10:05 a.m. Resident #51 was observed in bed, wearing a blue shirt. Her nails were long on her bilateral hands with brown and black substances under them. Resident #51 said they did not clean or clip her nails and held her hands up. On 09/10/2024 at 12:25 p.m., Resident #51 was observed in bed, wearing a blue shirt with white flowers. She stated it was a clean shirt. Her fingernails were long on her bilateral hands. She was eating her lunch. She was eating her sandwich but observed to be having some difficulty. It appeared her nails were cutting into the bun of the sandwich. She had spilled her fluids in her sippy cup onto her tray. During and observation and interview conducted on 09/10/2024 at 5:00 p.m. with the DON. Resident #51 was observed eating her dinner of chili with beans, rice, carrots and turnips, and a cup of ice cream. The resident was in her room attempting to feed herself. Resident #51's fingernails were observed to be extended past her fingers on both hands. The resident told the DON her nails were too long, and she wanted them trimmed. The resident was observed putting her fingers and nails into her cup of vanilla ice cream. The DON stated the long nails in her food including her ice cream was not acceptable and was an infection control issue. He stated his expectation was for the resident's fingernails to be cut by the nurse. After observing Resident #51 eating, the DON stated she needed more assistance with dining, more than just set-up. The DON stated he would check Resident #51's therapy evaluations. The DON stated even though the evaluations showed her weight loss was unavoidable due to Resident #51's medical conditions, they (the staff) could do better with assisting the resident to eat. Resident #51 was admitted with diagnoses included but not limited to Cerebrovascular Accident (CVA) with hemiplegia, seizures, recurrent depressive disorder, vascular dementia, severe protein-calorie malnutrition, anxiety, CVA with dysarthria, aphasia, and dysphagia, contracture of the right hand, muscle weakness, and acute pain due to trauma. Review of the quarterly MDS dated [DATE] showed a BIMS score of 03 which indicated severe cognitive impairment. Section GG Functional Abilities and Goals showed the resident required supervision or touching assistance for eating, dependent assistance for bathing and showering, and personal hygiene. Review of the care plans showed Resident #51 had an ADL (activities of daily living) self-care deficit related to ADL needs and participation vary, chronic medical conditions, confusion, impaired balance, limited mobility. The care plan was updated on 09/10/2024 (after start of survey). Interventions included but were not limited to the resident was dependent on staff for bathing needs, including transfer into and out of shower as of 05/23/2024. The resident needed supervision, verbal cues and / or touching/steadying of hands to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident as of 05/23/2024. Observe resident for changes in ADL capabilities. Notify nurse, therapy, and/or MD as indicated as of 05/23/2024. Review of the type of bathing provided to Resident #51 showed from 08/15/2024 to 09/09/2024 one shower on 08/29/2024. Full bed baths were provided on 08/15/2024, 08/19/2024, 08/22/2024, 09/02/2024, 09/05/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 11 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 A shower refusal on 09/09/2024. Level of Harm - Minimal harm or potential for actual harm Review of the Skin Monitoring: Comprehensive CNA Shower Review (shower sheets) showed to perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin to charge nurse immediately. Forward any problems to the DON for a review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number. The sheets showed the following: Residents Affected - Few 08/13/2024, skin clear, does need toenails cut, no signature by nursing 08/15/2024, skin clear, does not need toenails cut, no signature by nursing 08/20/2024, skin clear, does not need toenails cut, no signature by nursing 08/22/2024, skin clear, does not need toenails cut, no signature by nursing 08/27/2024, skin clear, does not need toenails cut, no signature by nursing 08/29/2024, skin clear, does not need toenails cut, no signature by nursing 09/02/2024, skin clear, does not need toenails cut, no signature by nursing 09/05/2024, skin clear, does not need toenails cut, no signature by nursing 09/09/2024, does not need toenails cut, no signature by nursing During an interview on 09/11/2024 at 10:47 a.m. the DON reviewed the shower sheets. The DON verified the medical record showed only one shower in 30 days on 08/29/2024. The DON stated the shower sheets did not indicate if the resident had a shower or bed bath consistently. The DON reviewed the shower sheets and confirmed they did not match the documentation in the medical record. The DON verified shower sheets existed for 08/20/2024, 08/27/2024 and 08/29/2024 and there was no documentation in the medical record. The DON reviewed the care plans for Resident #51. The DON stated he spoke with the resident's Occupational Therapist (OT) and the resident was on case load for Speech Therapy currently. The OT stated she was working with the resident but not related to eating or the need for assistance. The DON stated OT was picking the resident up today (09/11/2024). The DON stated he reviewed the resident's weight and it was actually up from admission. The DON stated the resident's weight had been fluctuating and staying steady. The DON stated the resident could use some assistance (with eating). The DON stated the aide and the floor nurse should be observing the resident's eating first and the need for eating assistance. The DON stated the resident was resistive to assistance. The DON stated the resident used to be out of her room more, but was refusing to come out of her room. During interview on 09/11/24 at 10:33 a.m. the DON stated the facility followed the RAI (Resident Assessment Instrument) for a care plan policy. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 12 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few October 2023, showed 1.1 Overview: The purpose of this manual is to offer clear guidance about how to use the Resident Assessment Instrument (RAI) correctly and effectively to help provide appropriate care. Providing care to residents with post-hospital and long-term care needs is complex and challenging work. Clinical competence, observational, interviewing and critical thinking skills, and assessment expertise from all disciplines are required to develop individualized care plans. As the process of problem identification is integrated with sound clinical interventions, the care plan becomes each resident's unique path toward achieving or maintaining their highest practical level of well-being. The RAI helps nursing home staff look at residents holistically-as individuals for whom quality of life and quality of care are mutually significant and necessary. Interdisciplinary use of the RAI promotes this emphasis on quality of care and quality of life. Chapter 4: Care Area Assessment (CAA) Process and Care Planning 4.1 Background and Rationale: Regulations require facilities to complete a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas. The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive plan of care. 4.2 Overview of the Resident Assessment Instrument (RAI) and Care Area Assessments (CAAs) The RAI-related processes help staff identify key information about residents as a basis for identifying resident-specific issues and objectives. In accordance with 42 CFR 483.21(b) the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and any services that would otherwise be required but are not provided due to the resident's exercise of rights including the right to refuse treatment. 4.3 What are the Care Area Assessments (CAAs)? The completed MDS must be analyzed and combined with other relevant information to develop an individualized care plan. 4.4 What Does the CAA Process Involve? Facilities use the findings from the comprehensive assessment to develop an individualized care plan to meet each resident's needs (42 CFR 483.20(d)). Based on observation, record review, and interview, the facility failed to develop a care plan for one (#45) of six residents sampled for skin conditions and failed to develop and implement an Activities of Daily Living care plan for two ( #44 and #51) of five residents sampled. Finding Included: 1 During an observation made on 09/08/24 at 02:20 p.m., Resident # 45 was observed lying down in bed dressed in a hospital grown from the morning until late in the afternoon. The resident was trying to say something but was not able to communicate. On 09/09/2024 at 11:00 a.m., Resident # 45 was observed lying down in bed dressed in his hospital grown. Resident #45's legs was observed with scabs leaking with yellow fluid on his right and left legs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 13 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of an admission Record showed Resident # 45 was admitted to the facility with diagnoses to include but not limited to Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side, psoriasis vulgaria, lymphedema, not elsewhere classified. Review of a Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status, (BIMS) score of 00, which indicated the resident had cognitive deficits. Review of a care plan focus showing Resident #45 had a rash related to Psoriasis and stasis dermatitis, initiated and revised on 9/10/2024. Review of the care plan goals showed Resident #45 will have no complications from rash through the review date, initiated on 9/10/2024. Review of the care plan intervention showed administer medication as ordered by the Medical Doctor (MD). Initiated on 9/10/2024. During an interview on 09/10/2024 at 4:00 p.m. with the Director of Minimum Data Set (MDS), she stated it was her responsibility to create the residents comprehensive care plan. She stated the Regional MDS nurse created Resident #45's skin care plan on 9/10/2024 after the surveyor asked to see his care plan related to his skin condition. She stated she should have created the skin care plan when she first identified the resident had a skin condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 14 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADLs) for dependent residents which included performing fingernail care and showers for two (#44 and #51) of 46 sampled residents. Residents Affected - Few Findings included: 1. An interview was conducted on 09/08/2024 at 09:50 a.m. with Resident #44. She was observed to be in bed, with a hospital gown on, hair was disheveled and unkempt. Resident #44 said she did not know when the last time she got a shower was, but she wanted a shower to wash her hands. Her fingernails were observed to extend past her fingertips with a dark brown, black substances under her bilateral nails. The resident said she had not had her fingernails cut and she does not like them long. Her right hand was observed to be curled into her palm and the resident pulled her fingers out and there was a red indented mark on her palm where her nail was resting in her palm. On 09/09/2024 at 10:01 a.m. Resident #44 was observed in her bed, hair disheveled, her bilateral fingernails were observed to extended past her fingertips. On 09/10/2024 at 9:45 a.m. Resident #44 was observed in her bed, hair combed. Her bilateral fingernails were observed to be extended past her fingertips. On 09/10/2024 at 5:08 p.m. the Director of Nursing (DON) observed Resident #44 eating her dinner of chili with beans, rice, carrots and turnips, and a cup of ice cream in the dining room. The DON verified Resident #44 had long nails. The DON stated the resident's nails should be observed during care by the aide and reported to the nurse. The aide or the activities person would do the resident's nails. The DON stated if we had someone on light duty, they would do nails also. The DON stated if a resident was a diabetic, the podiatrist would do their toenails. Resident #44 was observed to have food all over the front of her clothes. She was not being assisted by any staff members at the time, even though staff members were observed in the dining room. Resident #44 did not have a clothes protector on. The DON stated that the aides were to fill out shower sheets when they give residents a shower. The shower sheet was to be reviewed by the nurse if the resident refused, the nurse was to go speak with the resident to encourage a shower. If the resident still refused, the nurse was to document. Resident #44 was admitted to the facility with diagnoses that included but were not limited to dementia, senile degeneration of the brain, convulsions, recurrent depressive disorder, anxiety, sarcopenia, chronic pain, and cancer of the brain. Review of the quarterly Minimum Data Set, dated [DATE] showed a Brief Interview Mental Status (BIMS) score of 07 which indicated severe cognitive impairment. Section GG Functional Abilities and Goals showed the resident required supervision or touching assistance for eating, substantial/maximal assistance for bathing, showering, and personal hygiene. Review of the type of bathing provided to Resident #44 showed no showers from 08/13/2024 to 09/10/2024. Full bed baths were provided on 08/13/2024, 08/16/2024, 08/20/2024, 08/23/2024, 08/30/2024, 09/03/2024, 09/06/2024, 09/10/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 15 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 A sponge bath was provided on 08/27/2024. Level of Harm - Minimal harm or potential for actual harm Review of the Skin Monitoring: Comprehensive CNA Shower Review (shower sheets) showed to perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin to charge nurse immediately. Forward any problems to the DON for a review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number. The sheets showed the following: Residents Affected - Few 08/13/2024, skin clear, does not need toenails cut, no signature by nursing 08/16/2024, refused shower, skin clear, does not need toenails cut, no signature by nursing 08/20/2024, skin clear, needs toenails cut, no signature by nursing 08/23/2024, refused shower, does not need toenails cut, no signature by nursing 08/27/2024, skin clear, needs toenails cut, no signature by nursing 08/30/2024, skin clear, needs toenails cut, no signature by nursing 09/03/2024, refused shower, does not need toenails cut, no signature by nursing 09/06/2024, full bed bath, does not need toenails cut, no signature by nursing Review of the care plans showed Resident #44 had an ADL (activities of daily living) self-care deficit related to chronic medical conditions, dementia, ADL needs and participation varies revised on 09/09/2024. Interventions included but were not limited to the resident may need dependent assistance of 1 or 2 for ADL care as of 09/09/2024. This may fluctuate with weakness, fatigue, and weight bearing status. The resident needed limited to extensive assistance of 1-2 based on fatigue, weight bearing, weakness as of 05/23/2024. The resident needed supervision, verbal cues and / or touching/steadying of hands to bring food and/or liquid to the mouth and swallow food and / or liquid once the meal is placed before the resident as of 05/23/2024. Encourage and assist with all ADL tasks as indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, personal/oral hygiene, etc. as of 04/29/2024. During an interview on 09/11/2024 at 10:33 a.m. the DON reviewed the Skin Monitoring: Comprehensive CNA Shower Review sheets. The DON verified they showed the resident had refused showers on 08/16/2024, 08/23/2024 and 09/03/2024 and a full bed bath on 09/06/2024. The DON verified that the 08/20/2024, 8/27/2024, 08/30/2024 notes showed the resident needed her toenails cut. The DON stated the need for toenails to be cut would be subjective to the individual giving the bath. If the resident was diabetic, the aide was not expected to cut the toenails. The DON stated the nurse was to sign off on the shower sheet if the resident refused to take a shower. The DON verified the resident refused to shower based on documentation on 08/16/2024, 08/23/2024, 09/03/2024 and the nurse had not signed off on the shower sheet as had reviewed. The DON stated the aide should have taken the shower sheet to the nurse for review. The DON stated the aides needed more education. The DON stated that Resident #44 should have been offered a clothing protector during dining. The DON stated that she was in the dining room for more assistance, as needed. The DON reviewed the care plans and stated that the ADL care plan showed Resident #44 was to have supervision and cuing assistance for eating. The DON stated the ADL care plan showed to provide choice for care provisions, shower twice a week. The DON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 16 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the care plan showed the resident was resistive to care, non-compliant with showers, which was added on 09/11/2024 during survey. 2. During an observation conducted on 09/08/2024 at 09:31 a.m., Resident #51 was observed in bed. She was observed to have a flowered shirt on and she said she had been wearing the shirt for three days. She was also observed to have bilateral fingernails which extended past her fingertips with a black substance under them. During an observation conducted on 09/09/2024 at 10:05 a.m., Resident #51 was observed in bed, wearing a blue shirt. Her nails were long on her bilateral hands with brown and black substances under them. Resident #51 said they did not clean or clip her nails and held her hands up. On 09/10/2024 at 12:25 p.m. Resident #51 was observed in bed, wearing a blue shirt with white flowers. She stated it was a clean shirt. Her fingernails were long on her bilateral hands. She was eating her lunch, barbeque sandwich, baked beans, and cauliflower. She was eating her sandwich but observed to be having some difficulty. It appeared her nails were cutting into the bun of the sandwich. She had spilled her fluids in her sippy cup onto her tray. During and observation and interview conducted on 09/10/2024 at 5:00 p.m. with the DON, Resident #51 was observed eating her dinner of chili with beans, rice, carrots and turnips, and a cup of ice cream. The resident was in her room attempting to feed herself. Resident #51's fingernails were observed to be extended past her fingers on both hands. The resident told the DON her nails were too long, and she wanted them trimmed. The resident was observed putting her fingers and nails into her cup of vanilla ice cream. The DON stated the long nails in her food including her ice cream was not acceptable and was an infection control issue. He stated his expectation was for the resident's fingernails to be cut by the nurse. After observing Resident #51 eating, the DON stated she needed more assistance with dining, more than just set-up. The DON stated he would check Resident #51's therapy evaluations. The DON stated even though the evaluations showed her weight loss was unavoidable due to Resident #51's medical conditions, they (the staff) could do better with assisting the resident to eat. Resident #51 was admitted to the facility with diagnoses that included but not limited to Cerebrovascular Accident (CVA) with hemiplegia, seizures, recurrent depressive disorder, vascular dementia, severe protein-calorie malnutrition, anxiety, CVA with dysarthria, aphasia, and dysphagia, contracture of the right hand, muscle weakness, and acute pain. Review of the quarterly MDS dated [DATE] showed a BIMS score of 03 which indicated severe cognitive impairment. Section GG Functional Abilities and Goals showed the resident required supervision or touching assistance for eating, dependent assistance for bathing and showering, personal hygiene. Review of the type of bathing provided to Resident #51 showed from 08/15/2024 to 09/09/2024 one shower on 08/29/2024. Full bed baths were provided on 08/15/2024, 08/19/2024, 08/22/2024, 09/02/2024, 09/05/2024. A shower refusal on 09/09/2024. Review of the Skin Monitoring: Comprehensive CNA Shower Review (shower sheets) showed to perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin to charge nurse immediately. Forward any problems to the DON for a review. Use this form to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 17 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number. The sheets showed the following: Level of Harm - Minimal harm or potential for actual harm 08/13/2024, skin clear, does need toenails cut, no signature by nursing Residents Affected - Few 08/15/2024, skin clear, does not need toenails cut, no signature by nursing 08/20/2024, skin clear, does not need toenails cut, no signature by nursing 08/22/2024, skin clear, does not need toenails cut, no signature by nursing 08/27/2024, skin clear, does not need toenails cut, no signature by nursing 08/29/2024, skin clear, does not need toenails cut, no signature by nursing 09/02/2024, skin clear, does not need toenails cut, no signature by nursing 09/05/2024, skin clear, does not need toenails cut, no signature by nursing 09/09/2024, does not need toenails cut, no signature by nursing Review of the care plans showed Resident #51 had an ADL (activities of daily living) self-care deficit related to ADL needs and participation vary, chronic medical conditions, confusion, impaired balance, limited mobility. The care plan was updated on 09/10/2024 (after start of survey). Interventions included but were not limited to the resident was dependent on staff for bathing needs, including transfer into and out of shower as of 05/23/2024. The resident needed supervision, verbal cues and / or touching/steadying of hands to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident as of 05/23/2024. Observe resident for changes in ADL capabilities. Notify nurse, therapy, and/or MD as indicated as of 05/23/2024. During an interview on 09/11/2024 at 10:47 a.m. the DON reviewed the shower sheets. The DON verified the medical record showed only one shower in 30 days on 08/29/2024. The DON stated the shower sheets did indicate if the resident had a shower or bed bath consistently. The DON reviewed the shower sheets and confirmed they did not match the documentation in the medical record. The DON verified shower sheets existed for 08/20/2024, 08/27/2024 and 08/29/2024 and there was no documentation in the medical record. The DON reviewed the care plans for Resident #51. The DON stated he spoke with the resident's Occupational Therapist (OT) and the resident was on case load for Speech Therapy currently. The OT stated she was working with the resident but not related to eating or the need for assistance. The DON stated OT was picking the resident up today, 09/11/2024. The DON stated he reviewed the resident's weight and it was actually up from admission. The DON stated the resident's weight had been fluctuating and staying steady. The DON stated even though, the resident could use some assistance (with eating). The DON stated the aide and the floor nurse should be observing the resident's eating first and the need for eating assistance. The DON stated the resident was resistive to assistance. The DON stated the resident used to be out of her room more, but was refusing to come out of her room. Review of the facility's policy, ADL Care and Services, revised 01/2024 showed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 18 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Procedure: 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) are met. 2. The existence of a clinical diagnosis or condition does not alone justify at decline in a resident's ability to perform ADL's. 4. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident in accordance with the plan of care, including some appropriate support and assistance with: a. hygiene parentheses bathing, dressing, grooming, nail care and oral care parentheses; d. Dining (meals, hydration, and snacks). 6. To improve or minimize a resonance functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 7. The resident has the right to refuse any and all ADL care. The refusal of care will be documented in the resident's medical record with appropriate notification including the physician and resident representative. 8. The resident's response to interventions will be monitored, evaluated, and revised as appropriate. Event ID: Facility ID: 105305 If continuation sheet Page 19 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide quality care and services according to standards of practice related to medication administration and skin care treatment for one (#45) of three residents reviewed for wound care. Residents Affected - Few Finding included: During an observation made on 09/08/24 at 02:20 p.m., Resident #45 was observed lying down in bed dressed in a hospital grown from the morning until the late in the afternoon. Resident was trying to say something but was not able to communication. During an observation made on 09/09/2024 at 11:00 a.m., Resident #45 was observed lying down in bed dressed in his hospital grown. Resident #45 legs was observed with scabs leaking with yellow fluid on his right and left legs. During an interview on 09/10/2024 at 1:00 pm with Resident #45's representative, he stated [the resident] had been at the facility for a year. He was being seen by a vascular surgeon because the facility thought he could have cancer in his legs. He said the facility never followed back up on what was going on during the time he was seen by the surgeon. He stated the facility did not follow up with him regarding the resident's care. He was supposed to have an appointment with dermatology, but the facility did not make it right. He stated when [name of office] dermatology finally called him back, they told him they had to cancel his appointment and then they rescheduled the appointment for next year. He stated he did not know why [the resident] had to wait so long to been seen. He said [the resident] really needed to be seen by a skin doctor because his skin on his legs was really bad. Review of an admission Record showed Resident #45 was admitted to the facility with diagnoses to include but not limited to Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side, psoriasis vulgaria, lymphedema, not elsewhere classified. Review of a Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status, (BIMS) score of 00, which indicated the resident had severe cognitive impairment. Review of a care plan focus showed Resident #45 had a rash related to Psoriasis and stasis dermatitis, initiated and revised on 9/10/2024. Review of the care plan goals showed Resident #45 would have no complications from rash through the review date, initiated on 9/10/2024. Review of the care plan intervention showed administer medication as ordered by the Medical Doctor ( MD), initiated on 9/10/2024. Review of the Order summary showed an order for Otezla Oral Tablet Therapy pack 10 & 20 & 30 MG, give 1 tablet by mouth one time of day for psoriasis Follow started pack instruction. Further review of the EMAR (Electronic Medication Administration Record] showed on September 2nd, 4th, 5th 6th and 8th Otezla Oral tablet was code on 12 to indicate Medication on order from pharmacy. On September 9th the EMAR showed Staff V, Registered Nurse (RN) marked medication was administered to Resident #45 when it was verified not in stock. Review of the Treatment Administration Record ( TAR ) schedule for September showed an order for Fluocinolone Acetonide External Cream 0.01% (Fluocinolone Acetonide). Apply to Bilateral legs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 20 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few topically every day shift for stasis dermatitis. Further review of the EMAR showed Staff V signed off that she provided treatment on September 5th, 6th, and the 9th During an interview on 09/10/2024 at 2:00 pm. with Staff V, she stated she was not Resident 45's regular assigned nurse so she was not familiar with the resident's plan of care. She stated Resident #45 was not administered his oral medication Otezla today because it was not in stock. She reached out to pharmacy to have the resident's medication reordered. He was supposed to receive this medication for his legs. He was seen by the wound care nurse today, 09/10/2024, for treatments on his legs. Staff V stated when she observed the resident's legs today, she saw he had some drainage coming from his scabs on his legs but that was normal for what he had going on with his legs. She stated the wound care nurse was responsible for doing the resident's treatment. She stated that she signed off on the resident treatments and medication records even if she was not the person doing the resident treatments. She said she did it because she assumed the treatments were being done and they were not allowed to leave holes on the medication or treatment records. During an interview on 9/10/2024 at 2:30 p.m. with Staff EE, License Practical Nurse/Wound Care Nurse, she stated Resident #45 received Fluocinolone Acetonide External Cream applied on his legs by the floor nurses once a day. She reviewed the resident's treatment record and said that it showed Resident #45 was receiving his treatment once a day. She said Resident #45 was followed by wound care for his legs in the beginning of the year, but he was no longer seen by wound care. His wounds were closed at this time, and he was getting daily treatments done by his assigned nurse on day shift. During an interview on 09/10/2024 at 2:45 pm. with the Assistant Director of Nursing (ADON), she stated she heard that Staff V said she did not give Resident #45 his medication and that she signed off on his treatments even though she was not doing the treatments. She said, when it came to treatments, the nurse knew they were responsible for their own treatments on their residents. The wound care nurse was only responsible for wounds that were being followed by the wound care team. She said she would have to discuss this situation with the Director of Nurses. During an interview on 09/10/24 at 4:45 p.m., with The Director of Nurses (DON), he stated this morning when the nurse was doing her med pass, she was not able to find the Otezla for Psoriasis - A medication for Resident #45's skin condition. He said she needed to inform the physician and then contact the pharmacy. He said he could not answer why the resident's medication was not available. Normally when a medication was missing, they contacted the pharmacy and reorder. The resident was moved from one hall to another, and the resident's medication might not have followed him over. The expectation was that the nurse should have reordered the resident's medications before the medication was out. Staff V told him she placed the order to the pharmacy and notified the physician. When it came to the facility treatment process, treatments were done by the floor nurses. The floor nurses were responsible for signing off on their own treatments. The wound care nurse had a list of residents that she saw. The wound care nurse took care of the resident's wound dressing and not the treatments. Review of the facility policy titled, Standards and Guidelines: Physician Orders, Revised date 01/2024 showed Guidelines: Orders and administration of medication and treatment will be consistent with principles of safe and effective order writing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 21 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide indwelling urinary catheter care and services to prevent leakage and breaks in tubing for two (#82 and #13) of ten sampled residents during two of two days observed (9/8/2024 and 9/9/2024). Findings included: 1. On 9/8/2024 at 10:45 a.m., Resident #82 was observed seated in her wheelchair and was slowly self propelling down the hall from her room. An attempt to interview the resident revealed she had cognition deficits and was only able to answer some simple yes and no questions. She kept saying, I just want to go back to my room, I want to go to bed. Passing staff told her, ok, in a minute, but we have lunch soon. Further observations revealed when the resident was self propelling in her wheelchair down the hallway, she was noted with an indwelling urinary catheter. The catheter bag was observed appropriately hanging under the seat of the wheelchair. However, the tubing from the bag to the resident was observed in excess slack, dragging on the floor with approximately six to seven inches on the floor. Further, as the rear wheelchair tires were rolling, the tubing was observed either very close to being ran over, or was touching the tire as the resident and wheelchair was moving. She remained parked near the unit station and room [ROOM NUMBER] for a period of time with staff continually passing her and saying hello. However, staff did not address the catheter on the floor. Photographic evidence was obtained. On 9/8/2024 at 10:56 a.m., Staff D, Certified Nursing Assistant (CNA) was observed to walk by the resident as the resident shouted, I just want to go get into my bed. Staff D accommodated her while pushing her back to her room, while she was in her wheelchair. While Staff D was pushing her down the hallway the catheter tubing was still observed dragging on the floor under the resident and touching the rear wheelchair tires. Staff D brought her into her room and then left as the tubing was still on the floor. On 9/8/2024 at 11:30 a.m., Resident #82 was observed in the main dining room seated in her wheelchair and positioned at a table. She had just received her lunch meal tray. Further observations revealed her indwelling catheter tubing was again dragging on the floor near her rear tire. Staff F, Registered Nurse (RN) and Staff E, RN had just repositioned the catheter up off the floor not even seven minutes prior to this observation. She remained in the main dining room until 12:13 p.m. when an unidentified staff member assisted the resident back to her room by pushing her while in her wheelchair with the tubing dragging the floor. On 9/9/2024 at 6:50 a.m., Resident #82 was observed seated in her wheelchair at the 100/200 nurse station. She was dressed for the day and well groomed. She had a blanket over her lap, legs, and pulled up to her neckline. At 6:59 a.m., she was noted to leave the area and self propelled herself down the hall, towards her room. Both of her feet were on the wheelchair foot pedals and she was using both of her hands to turn the tires to move forward. She was observed with her indwelling urinary catheter tubing dragging on the floor beneath her with approximately six inches of tubing on the floor. The rear wheelchair tire was observed brushing up against the tubing as she was moving forward. During the time she was moving towards her room, there were many staff who passed by her. Some stopped to say hello and moved on. No staff was observed to identify the tubing on the ground. Therefore, it was not reported to nursing to be readjusted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 22 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm On 9/10/2024 at 12:20 p.m. an interview with Resident #82's responsible party revealed she was aware [the resident] was utilizing a urinary catheter and was made aware yesterday, 9/9/2024, of the catheter removal. The responsible party said there had been times when she had come in to visit and had seen [the resident] while in her wheelchair and with the catheter bag and tubing dragging on the floor. She said she had not thought anything about it until now during the interview. Residents Affected - Few An interview with Resident #82 could not be obtained as she had cognitive deficits and could not speak specifically to her catheter care and other medical care/services. Review of Resident #82's medical record,diagnosis sheet, showed diagnoses which included but were not limited to Dementia, Neuromuscular Dysfunction of Bladder, and Presence of Urogenital Implants. Review of the current Minimum Data Set (MDS) admission assessment, dated 6/12/2024, revealed Cognition/Brief Interview Mental Status or BIMS score 9 of 15, which indicated the resident had moderate cognitive impairments; Activities of Daily Living ADL - Toileting = Dependent, Dressing = Substantial/Maximal assistance, Personal Hygiene = Dependent; Bowel and Bladder - Checked for use of Indwelling catheter and always incontinent of bowel. Review of the current Physician's Order Sheet for month 9/2024, and reviewed at 12:00 p.m. on 9/9/2024 revealed the following orders: 1. Indwelling Urinary Catheter change catheter bag and tubing every night shift staring on 18th; 2. Indwelling Urinary Catheter monitor every shift and notify the physician of changes in urinary appearance and or urinary output; 3. Indwelling Urinary Catheter change 16fr 10 ml catheter tubing, and collection bag as need when medically necessary; 4. Indwelling Urinary Catheter Encourage and assist resident to use/apply leg bag when out of bed and/or as tolerated/requested A new order on 9/9/2024 revealed to remove Foley Catheter for voiding trial one time only on 9/9/2024. On 9/11/2024 at 9:25 a.m., an interview with Staff G, 100/200 Unit Manager revealed she knew Resident #82 well and she had spoken with her responsible party at times when she visited the resident. Staff G said she usually rounded the unit multiple times a shift and looked out for resident care needs, staff delivery of care, and general resident safety. She confirmed Resident #82 utilized a urinary catheter up to the afternoon of 9/9/2024. Staff G revealed that herself, along with other nurses on the floor would observe the catheter for placement, patency, safety and infection risks. Staff G said if any resident's catheter bag and/or tubing was observed on the floor while either in bed or while in a wheelchair, the tubing and bag should be positioned safely and off the floor. 2. During an interview on 09/08/2024 at 9:10 a.m., Resident #13 was observed lying in bed dressed in a hospital gown. A catheter bag was observed on the floor underneath the bed. The resident was leaning to the right of the bed hanging onto the railing of the bed. She stated when she first came to the facility, she was getting therapy to help her with her mobility but most recently she has not been going to therapy anymore and would like to start going to therapy again so she can become more independent. During an observation and interview with Resident #13 on 09/10/2024 at 1:00 p.m., she was observed lying in bed dressed in a gown and clean in appearance, there was a catheter bag located on the floor with the privacy side up. She stated she no longer had concerns about therapy because she was transferring to another facility at the end of the week so she would be closer to her family. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 23 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 she would worry about therapy when she got to the new facility. Level of Harm - Minimal harm or potential for actual harm Review of Resident #13's admission Record showed Resident #13 was admitted to the facility with diagnoses of anxiety disorder, major depressive disorder, dementia, and neuromuscular dysfunction of bladder. Residents Affected - Few Review of Resident #13's care plan dated 05/24/2024 showed, the resident has a risk for injury/infection presence of indwelling catheter secondary to a diagnosis of neurogenic bladder, start date 05/24/2024. With a goal of the resident will be free of complications catheter use through next review. With a focus of Position catheter bag and tubing so that it promotes dignity and drainage, Privacy bag/cover in place, provide catheter care per orders, Urology consult and follow up as indicated/ordered. During an interview on 09/11/2024 at 9:00 a.m., with Staff K,CNA, she stated Resident #13 was a total care resident who chose to stay in bed. She stated the resident would occasionally go to the dining room for food. She stated the resident was a 2 person [mechanical]Hoyer lift. Staff K stated she provided the resident with Peri Care, and emptied the catheter bag every shift, she stated the bag should always be placed with the privacy side out, and hanging below the bladder, she stated there was a hook on the bed they normally clipped it to. During an interview on 09/11/2024 at 9:11 a.m., with Staff L, LPN, she stated residents with catheters received perineal care to include cleaning the area. She stated residents who are mobile received a [urine collection] bag that attached to their leg, and they made sure it was covered by their clothing. She stated for residents who were in bed the catheter bag should be placed at the bottom of the bed below the bladder. She stated the catheter bags should never be placed on the floor. Review of the facilities Catheter Care, dated 10/2020, revealed Standard: The facility will maintain infection control guidelines related to catheter use and catheter care to minimize catheter associated infections. Guideline: The clinical staff will receive education and training related to providing catheter care to minimize catheter associated infections. 1. Use standard precautions when handling or manipulating the drainage system, catheter tubing, or drainage bag .3. Ensure the drainage spigot is not touching the floor, the tubing is free of kinks, the catheter is capped at an appropriate level to promote urine flow, and dignity is maintained. Catheter coverings are not required when drainage bags are out of sight from the public or per the residence preference. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 24 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure trauma informed care was provided for one (#39) of one resident with post-traumatic stress disorder (PTSD). The facility did not ensure PTSD triggers were on Resident #39's care plan. The facility did not ensure staff was trained annually on trauma informed care as the facility policy indicated. Residents Affected - Few Findings Included: Review of admission Record showed Resident #39 was initially admitted to the facility diagnoses which included major depressive disorder, schizoaffective disorder, unspecified psychosis, post-traumatic stress disorder, other specified persistent mood disorders, anxiety disorder, dementia. Review of Resident #39's Minimum Data Set (MDS) assessment dated [DATE], Section C-Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. Review of Resident #39's Care Plan dated revealed the following: A focus area initiated on 7/24/24 showed, the resident had experienced a traumatic event which had impacted their emotional health as evidenced by (AEB) PTSD nightmares. The goal showed, frequency or severity of the trauma-related symptoms would not increase. The interventions showed, Alert MD/designee of any significant changes in behavior. Provide a quiet, non-threatening environment as indicated. Respect resident's space and privacy. Encourage and assist the resident to have contact with family/friends as able. On 09/09/2024 at 11:50 a.m., Resident #39 was observed lying in his bed and speaking with Staff O, Licensed Practical Nurse (LPN). Resident #39 told Staff O he did not want a particular person in his room because that person tried to kill his girlfriend. The name of the person mentioned by Resident #39 was unintelligible. Resident #39 repeated his statement that he did not want a particular person in his room because that person tried to kill his girlfriend. Staff O, LPN, did not respond to the resident or acknowledge the resident's statement. An interview was conducted with Staff O, Licensed Practical Nurse (LPN) on 09/09/2024 at 11:50 a.m. Staff O said he was not aware of the care plan for Resident #39. He said he did not look at the care plans he only gave medications to the resident. Staff O, LPN said he was not aware of any psychiatric issues Resident #39 might have. An interview was conducted with The ADON (Assistant Director of Nursing) on 09/10/2024 at 10:30 a.m. The ADON she said nurses could check the care plans to see if there was anything new or different with the resident. She said they could also check the care plan if there were any new behaviors or behavior triggers on the care plan. She said the care plan was the big key for care. The nurse might put any new issues they encountered with a resident on the report/care sheet during their shift. An interview was conducted with Staff I, LPN, on 09/11/2024 at 9:54 a.m. Staff I, who was taking care of Resident #39 on this day, stated she definitely had one resident on her assignment who was diagnosed with PTSD. She stated the name of the resident whom she said has the PTSD diagnosis, however, it was not Resident #39. The resident Staff I indicated did not have a PTSD diagnosis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 25 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with the DON (Director of Nursing) on 09/11/2024 at 10:15 a.m. He said the nurses on the floor should be familiar with the resident care plans. The nurses also had the task listings available for review on their assigned resident's electronic medical records. He said the staff also needed to check the [a system for organizing patient information that nursing staff use to create care plans] as well as the care plan. The DON said he believed the underlying cause of the Resident #39's PTSD was related to nightmares, but he was not sure. He said care plan interventions were monitored through feedback from the resident, social service visits, daily care and community visits. He said the facility could ensure care was consistent with the care plan through education. He said the education portion was done during the orientation process and there was no continuing education done. Changes in condition were reported to the MD and to the family. He said the care for the resident with PTSD was based on listing out the medical diagnoses and identify to see if there was PTSD and trauma. The care plan should be based on the history of trauma and the triggers. Changes in the care plan and resident's condition were communicated to the staff after care plan meetings through unit managers and MDS (Minimum Data Set) Assessments. An interview was conducted with Staff R, RN MDS Coordinator on 09/11/2024 at 2:00 p.m. He said his role in the care plan process was related to nursing. During review of the resident's care plan, he said the Focus section regarding the type of trauma the resident experienced would be based on the psychiatric evaluation. If the psychiatric evaluation did not have the specific PTSD trauma it would not be listed. He said this is the same case for the interventions, if the psychiatric evaluation does not list specific triggers they would not be listed on the care plan. Review of Resident #39's current physician's orders revealed the resident is currently taking the following medications: -Celexa oral tablet 20 MG (Citalopram Hydrobromide)/Give 1 tablet by mouth one time a day related to major depressive disorder -Trazodone HCI oral tablet 100 MG (Trazodone HCI)/Give 1 tablet by mouth in the evening for insomnia related to major depressive order -Ativan Injection Solution 2MG/ML (Lorazepam)/Inject 0.25 ml intramuscularly every 24 hours as needed for seizures Review of Resident #39's Subsequent Psychiatric Evaluation dated 05/15/2022 revealed the resident had a PTSD diagnosis related to nightmares. Review of the policy - Trauma Informed Care Issued 04/2019 and revised 01/2024 showed The facility will ensure each resident receives care and services to attain and maintain the highest practicable psycho-social well-being. The procedure included: 1. Residents will be assessed for a history of PTSD upon admission and as needed. 2. When Trauma has been identified the Social Services Director or Designee will inform the resident's attending physician and request both Psychiatry and Psychology Services for the resident. 3. Through resident interview and Psych Services, a Comprehensive Plan of Care will be developed with the interdisciplinary Team to reduce the risk of re-traumatization. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 26 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Level of Harm - Minimal harm or potential for actual harm 4. Residents who are trauma survivors will receive culturally competent, trauma-informed care, in accordance with professional standards of practice and accounting for residents' experiences and preferences, in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. 5. Staff will be educated on Trauma Informed Care upon hire and annually. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 27 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide residents and visitors with up to date and correct daily staffing posting information. It was determined the facility had not updated this sheet for a total of three days. Residents Affected - Few Findings included: On 9/8/2024 at 8:33 a.m., an observation was made of the facility's entrance lobby. A desk in the lobby area was observed with a stand up clear plastic document holder. The holder had encased a Daily Staffing Projection sheet. The sheet had information with the date, how many nurses and how many Certified Nursing Assistants (CNAs) were working for each of the three shifts, and the resident census. The sheet showed a date of 9/5/2024, which was three days prior to the current date reviewed, 9/8/2024. The sheet had not been updated to reflect the current date, the current staffing numbers per each of the three shifts, or the current resident census. The sheet reflected a resident census of 104. An interview with the Front Desk receptionist revealed she was aware of the form because it was at her desk area. However, she was not able to explain who updated the form. An interview with the weekend supervisor, who was also the Certified Dietary Manager, revealed the current resident census was 111. At 9:02 a.m. an interview with the Nursing Home Administrator (NHA) revealed the Daily Staffing Projection sheet was updated every day and it was the Staffing Coordinator's responsibility to update and replace the sheet daily. He confirmed the front lobby desk area was the only place they posted this sheet. The NHA revealed on weekends, the assigned weekend supervisor would update and replace this sheet. He reviewed the current sheet and confirmed it had not been updated for three days. He confirmed that today, Sunday 9/8/2024, the Certified Dietary Manager was responsible for updating and posting the current day's Daily Staffing Projection sheet. On 9/9/2024 at 6:10 a.m. the building was entered. The Staffing Coordinator Staff B was met with and revealed what the Daily Staffing Projection sheet expectations were. She was observed updating the sheet as the building was entered. Staff B was asked who was responsible for changing and updating that form. She said it was her responsibility to change and update the form on a daily basis Monday through Friday. She said she was not at the facility on the weekends and it was the responsibility of the weekend supervisor to change and update it on Saturday and Sunday. Staff B was made aware from the NHA that the sheet had not been updated and changed since 9/5/2024. She said she was off on 9/6/2024 and did not know why it was not changed. On 9/11/2024 at 10:00 a.m., the Nursing Home Administrator said the facility did not have a specific policy with regards to the daily nursing assignment posting. He did say it was their standard to update and have the current nursing assignment posting available for residents and visitors to see. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 28 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure the medication error rate was less than 5% for three (#14, #93, #498) of four sampled residents who were administered medications. This resulted in seven errors from 35 medication administration opportunities for a medication error rate of 20.00%. Residents Affected - Few Findings included: 1. On 09/10/2024 at 9:55 a.m., Resident #498 was observed sitting in her room. Staff U, Licensed Practical Nurse (LPN) was observed passing medications. Verified a total of 9 medications were in the medication cup The following medications were observed as administered to Resident #498: Aspirin delayed release 81 mg (milligrams) daily for DVT prophylaxis (deep vein thrombosis) Cefuroxime Axetil 500 mg two times a day for pneumonia for 2 days Ventolin HFA inhalation Aerosol Solution 108 mcg/ACT (microgram/actuation) 1 puff three times a day for COPD (Chronic Obstructive Pulmonary Disease) Glimepiride 1 mg by mouth in the morning for Diabetes Iron 325 mg daily for supplement Lasix 40 mg give daily for CHF (Congestive Heart Failure) MiraLax 17 GM (gram)/scoop daily for constipation mix in 4-8-ounce water Duloxetine HCL delayed release 30 mg twice a day for major depression Gabapentin 300 mg give two times a day for nerve pain Pro-Stat oral liquid give 30 ml by mouth twice a day for supplement Topiramate 200 mg give 2 tablets twice a day for migraine headaches Review of the physician orders and Medication Administration Review (MAR) for September showed Azithromycin 500 mg daily for pneumonia for 2 days, not observed administered, but documented as given Flonase allergy relief Nasal Suspension 50 mcg/act (Fluticasone Propionate Nasal) 1 spray both nostrils in the morning for allergies, not observed administered, but documented as given Fluticasone-Salmeterol 250-50 mcg/act aerosol powder, 1 puff twice a day for chronic resp. failure with hypoxia Rinse mouth after use, not observed administered, but documented as given (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 29 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #498 was admitted on [DATE] and readmitted on [DATE]. Review of admission record showed diagnoses included but not limited to Cerebrovascular Accident (CVA) with hemiplegia, heart failure, chronic respiratory failure with hypoxia, COPD, and asthma. Review of the care plans showed Resident #498 had a care plan for antibiotic therapy related to infection as of 09/09/2024. Interventions included but not limited to administer antibiotic medications as ordered by physician. The resident was at risk for altered respiratory status/difficulty breathing related to episodes of shortness of breath, pneumonia, COPD/asthma. Interventions included but not limited to administer medication/inhalers/nebulizers as ordered as of 09/09/2024. 2. On 09/10/2024 at 10:25 a.m. Resident #93 was observed sitting in her room. Staff V, Registered Nurse (RN) was observed passing medications. The following medications were observed as administered to Resident #93: Aspirin 81 mg daily for DVT prophylaxis Clopidogrel Bisulfate 75 mg daily for blood clot prevention Metoprolol Succinate ER Extended Release 24 hour 50 mg in the morning for CHF, hold for heart rate less than 60 Metformin HCL 500 mg twice a day for diabetes Midodrine HCL 5 mg three times a day, please hold for systolic over 120 Review of the physician orders and Medication Administration Review (MAR) for September showed MiraLax 17 gm give by mouth for constipation for 5 days, mix with 4-6 oz of liquid, not observed administered, but documented as given Ranolazine ER 12-hour 500 mg for chronic chest pain, not observed administered, but documented as given Sennosides 8.6 mg give 2 tablets twice a day for constipation for 5 days, not observed administered, but documented as given Review of progress notes showed on 09/10/2024 at 9:35 a.m. the Nurse Practitioner was notified that a.m. meds may be administered late this a.m. Nurse Practitioner gave ok to give meds by noon. Resident #93 was admitted on [DATE]. Review of the admission record showed diagnoses included but not limited to COVID-19, diabetes, atherosclerotic heart disease, hypertension, pneumonia, history of falling, Transient Ischemic attack, muscle weakness, and reduced mobility. Review of the care plans showed Resident #93 had a care plan for altered cardiovascular status related to hyperlipidemia, hypertension as of 08/16/2024. Interventions included but not limited to administer medications per MD order. Care plan for resident was at risk for bowel irregularity related to decreased mobility, disease process as of 08/16/2024. Interventions included but not limited to administer medications as per MD orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 30 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 3. On 09/10/2024 at 10:32 a.m. Resident #14 was observed sitting in her room. Staff W, Registered Nurse (RN) was observed passing medications Level of Harm - Minimal harm or potential for actual harm The following medications were observed as administered to Resident #14 Residents Affected - Few Eldertonic oral liquid give 15 ml daily for supplements House liquid protein 30 ml by mouth 100% Miralax 17 gm/scoop in the morning for constipation mix with 8 oz. of water Xeljanz XR ER 24-hour 11 mg daily for RA do not crush Advair diskus Aerosol Powder Breath Activated 250-50 mcg/dose 1 puff orally two times a day for asthma rinse mouth after use Calcium 500 mg twice a day for supplement Docusate Sodium 100 mg twice a day for constipation Eliquis 2.5 mg twice a day for blood clots prevention Ferrous Sulfate 325 mg twice a day for supplementation Senna 8.6 mg give 2 tablets twice a day for GI motility, hold for loose stool Review of the physician orders and Medication Administration Review (MAR) for September showed Calcium 600 mg twice a day for supplement was ordered on 03/11/2024 Resident #14 was admitted on [DATE]. Review of the admission record showed diagnoses included but not limited to rheumatoid arthritis, disorder of lung, severe protein-calorie malnutrition, and hypertension. Review of the care plans showed Resident #14 had a care plan for at risk for alteration in nutritional status related to BMI under 18, history of significant weight loss, history of malnutrition, dependency for meals, need for nutritional supplements and diagnoses / history including: rheumatoid arthritis, history of dysphagia and hypertension. Interventions included but not limited to encourage intake of supplements and / or snacks provided. Provide supplement as ordered. Review of progress notes showed on 09/10/2024 at 10:26 a.m. the Nurse Practitioner was notified that a.m. meds may be administered late this a.m. Nurse Practitioner gave ok to give meds by noon. Assistant DON During an interview on 09/11/2024 at 10:57 a.m. the Director of Nursing (DON) reviewed the MARs for Resident's #498, #93 and #14 for medications administered. The DON stated all the medications should have been given as per orders. The DON stated the nurses should not have documented medications had been administered when they had not been administered. The DON said the missed medications were considered medication errors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 31 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The DON verified Resident #93's medical provider had been notified at 9:35 a.m., 1 hour before the resident's medication administration was given. The DON stated the notification of the nurse practitioner was a blanket statement letting them know the medications were going to be late due to scheduling. The DON stated they had schedule changes that morning due to call offs. Resident #93 was given Midodrine at 10:30 a.m. per the DON and the next dose was scheduled for 1:00 p.m. or 2 ½ hours later. The DON verified Resident #93's Midodrine was given at 2:00 p.m. The DON verified the Calcium order for Resident #14 was for 600 mg not 500 mg as was administered. During an interview on 09/11/2024 at 12:19 p.m. the Medical Provider / APRN (Advanced Practice Registered Nurse) stated all medications should be given as ordered. The APRN stated if medications are not given, it should be documented and reported to the provider. The APRN said if the medications are given late, the provider should also be notified. She stated if a medication that was ordered three times a day was given late, the provider should be called for input into a possible order change / time change. The APRN stated it was not good for a nurse to document what had not been given. Review of the facility's policy, Medication Administration, revised 01/2024 showed medications are ordered and administered safely and as prescribed. Guideline: Medications will be administered safely and as prescribed by only licensed personnel. Procedure: 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The Director of Nursing Services supervises and directs all personnel who administer medications and / or have related functions 3. Medications are administered in accordance with prescriber orders, including any required time limit. 4. Medication administration times are determined by resident need, preference, and benefit, not staff convenience. 5. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 6. Medications are administered within one hour before or after their prescribed time, unless otherwise specified. 9. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. 16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document the rationale in the residence medical record and notify the physician and responsible party if indicated. 17. As required or indicated for a a medication, the individual administering the medication records in the residence medical record: a. the date and time the medication was administered; B. The dosage; C. The route of administration; F. Any results achieved and when those results were observed if applicable, and G. The signature and title of the person administering the drug. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 32 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1. the medical record contained accurate and complete documentation for three (#498, #93, #14) of 46 sampled residents related to bathing and for one (#51) of four sampled residents related to medication administration. Findings included: 1. On 09/10/2024 at 9:55 a.m. ,Resident #498 was observed sitting in her room. Staff U, Licensed Practical Nurse (LPN) was observed passing medications. Verified a total of 9 medications in the medication cup The following medications were observed as administered to Resident #498: Aspirin delayed release 81 mg (milligrams) daily for DVT prophylaxis (deep vein thrombosis) Cefuroxime Axetil 500 mg two times a day for pneumonia for 2 days Ventolin HFA inhalation Aerosol Solution 108 mcg/ACT (microgram/actuation) 1 puff three times a day for COPD (Chronic Obstructive Pulmonary Disease) Glimepiride 1 mg by mouth in the morning for Diabetes Iron 325 mg daily for supplement Lasix 40 mg give daily for CHF (Congestive Heart Failure) MiraLax 17 GM (gram)/scoop daily for constipation mix in 4-8-ounce water Duloxetine HCL delayed release 30 mg twice a day for major depression Gabapentin 300 mg give two times a day for nerve pain Pro-Stat oral liquid give 30 ml by mouth twice a day for supplement Topiramate 200 mg give 2 tablets twice a day for migraine headaches Review of the physician orders and Medication Administration Review (MAR) for September showed Azithromycin 500 mg daily for pneumonia for 2 days, not observed administered, but documented as given Flonase allergy relief Nasal Suspension 50 mcg/act (Fluticasone Propionate Nasal) 1 spray both nostrils in the morning for allergies, not observed administered, but documented as given Fluticasone-Salmeterol 250-50 mcg/act aerosol powder, 1 puff twice a day for chronic resp. failure with hypoxia Rinse mouth after use, not observed administered, but documented as given (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 33 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #498 was admitted on [DATE] and readmitted on [DATE]. Review of admission record showed diagnoses included but not limited to Cerebrovascular Accident (CVA) with hemiplegia, heart failure, chronic respiratory failure with hypoxia, COPD, and asthma. 2. On 09/10/2024 at 10:25 a.m., Resident #93 was observed sitting in her room. Staff V, Registered Nurse (RN) was observed passing medications. The following medications were observed as administered to Resident #93: Aspirin 81 mg daily for DVT prophylaxis Clopidogrel Bisulfate 75 mg daily for blood clot prevention Metoprolol Succinate ER Extended Release 24 hour 50 mg in the morning for CHF, hold for heart rate less than 60 Metformin HCL 500 mg twice a day for diabetes Midodrine HCL 5 mg three times a day, please hold for systolic over 120 Review of the physician orders and Medication Administration Review (MAR) for September showed MiraLax 17 gm give by mouth for constipation for 5 days, mix with 4-6 oz of liquid, not observed administered, but documented as given Ranolazine ER 12-hour 500 mg for chronic chest pain, not observed administered, but documented as given Sennosides 8.6 mg give 2 tablets twice a day for constipation for 5 days, not observed administered, but documented as given Resident #93 was admitted on [DATE]. Review of the admission record showed diagnoses included but not limited to COVID-19, diabetes, atherosclerotic heart disease, hypertension, pneumonia, history of falling, Transient Ischemic attack, muscle weakness, and reduced mobility. 3. On 09/10/2024 at 10:32 a.m. Resident #14 was observed sitting in her room. Staff W, Registered Nurse (RN) was observed passing medications The following medications were observed as administered to Resident #14 Eldertonic oral liquid give 15 ml daily for supplements House liquid protein 30 ml by mouth 100% Miralax 17 gm/scoop in the morning for constipation mix with 8 oz. of water Xeljanz XR ER 24-hour 11 mg daily for RA do not crush Advair diskus Aerosol Powder Breath Activated 250-50 mcg/dose 1 puff orally two times a day for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 34 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 asthma rinse mouth after use Level of Harm - Minimal harm or potential for actual harm Calcium 500 mg twice a day for supplement Docusate Sodium 100 mg twice a day for constipation Residents Affected - Few Eliquis 2.5 mg twice a day for blood clots prevention Ferrous Sulfate 325 mg twice a day for supplementation Senna 8.6 mg give 2 tablets twice a day for GI motility, hold for loose stool Review of the physician orders and Medication Administration Review (MAR) for September showed House Supplement 60 ml 100% consumed, not observed administered, but documented as given Calcium 600 mg twice a day for supplement was ordered on 03/11/2024 Resident #14 was admitted on [DATE]. Review of the admission record showed diagnoses included but not limited to rheumatoid arthritis, disorder of lung, severe protein-calorie malnutrition, and hypertension. During an interview on 09/11/2024 at 10:57 a.m. the Director of Nursing (DON) reviewed the MARs for Resident's #498, #93 and #14 for medications administered. The DON stated the nurses should not have documented medications had been administered when they had not been administered. The DON said the missed medications were considered medication errors. During an interview on 09/11/2024 at 12:19 p.m. the Medical Provider / APRN (Advanced Practice Registered Nurse) stated all medications should be given as ordered. The APRN stated if medications are not given, it should be documented and reported to the provider. The APRN said if the medications are given late, the provider should also be notified. She stated if a medication that was ordered three times a day was given late, the provider should be called for input into a possible order change / time change. The APRN stated it was not good for a nurse to document what had not been given. 2. An observation was conducted on 09/08/2024 at 09:31 a.m. Resident #51 was observed to be in bed. She was observed to have a flowered shirt on and she said she had been wearing the shirt for three days. She was also observed to have bilateral fingernails which extended past her fingertips with a black substance under them. An observation was conducted on 09/09/2024 at 10:05 AM Resident #51 was observed to be in bed, wearing a blue shirt. Her nails were long on her bilateral hands with brown and black substances under them. Resident #51 said they did not clean or clip her nails and held her hands up. On 09/10/2024 at 12:25 p.m. Resident #51 was observed to be in bed, wearing a blue shirt with white flowers. She stated it was a clean shirt. Her fingernails were long on her bilateral hands. She was eating her lunch, barbeque sandwich, baked beans, and cauliflower. She was eating her sandwich but observed to be having some difficulty. It appeared her nails were cutting into the bun of the sandwich. She had spilled her fluids in her sippy cup onto her tray. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 35 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #51 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed the diagnoses included but not limited to Cerebrovascular Accident (CVA) with hemiplegia, seizures, recurrent depressive disorder, vascular dementia, severe protein-calorie malnutrition, anxiety, CVA with dysarthria, aphasia, and dysphagia, contracture of the right hand, muscle weakness, acute pain due to trauma, history of falling, age related OP, and hypertension. Review of the quarterly MDS dated [DATE] showed a BIMS score of 03 (severe impairment). Section GG Functional Abilities and Goals showed the resident required supervision or touching assistance for eating, dependent assistance for bathing and showering, personal hygiene. Review of the type of bathing provided to Resident #51 showed from 08/15/2024 to 09/09/2024 one shower on 08/29/2024. Full bed baths were provided on 08/15/2024, 08/19/2024, 08/22/2024, 09/02/2024, 09/05/2024. A shower refusal on 09/09/2024. Review of the Skin Monitoring: Comprehensive CNA Shower Review (shower sheets) showed to perform a visual assessment of a resident's skin when giving the resident a shower. Report any abnormal looking skin to charge nurse immediately. Forward any problems to the DON for a review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number. The sheets showed the following: 08/13/2024, skin clear, does need toenails cut, no signature by nursing 08/15/2024, skin clear, does not need toenails cut, no signature by nursing 08/20/2024, skin clear, does not need toenails cut, no signature by nursing 08/22/2024, skin clear, does not need toenails cut, no signature by nursing 08/27/2024, skin clear, does not need toenails cut, no signature by nursing 08/29/2024, skin clear, does not need toenails cut, no signature by nursing 09/02/2024, skin clear, does not need toenails cut, no signature by nursing 09/05/2024, skin clear, does not need toenails cut, no signature by nursing 09/09/2024, does not need toenails cut, no signature by nursing During an interview on 09/11/2024 at 10:47 a.m. the DON reviewed the shower sheets. The DON verified the medical record showed only one shower in 30 days on 08/29/2024. The DON stated the shower sheets do not indicate if the resident had a shower or bed bath consistently. The DON reviewed the shower sheets and confirmed they did not match the documentation in the medical record. The DON verified shower sheets existed for 08/20/2024, 08/27/2024 and 08/29/2024 and there was no documentation in the medical record. Review of the facility's policy, Medication Administration, revised 01/2024 showed medications are ordered and administered safely and as prescribed. Guideline: Medications will be administered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105305 If continuation sheet Page 36 of 37 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairway Oaks Center 13806 N 46th St Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete safely and as prescribed by only licensed personnel. Procedure: 3. Medications are administered in accordance with prescriber orders, including any required time limit. 4. Medication administration times are determined by resident need, preference, and benefit, not staff convenience. 5. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 9. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. 16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document the rationale in the residence medical record and notify the physician and responsible party if indicated. 17. As required or indicated for a medication, the individual administering the medication records in the residence medical record: a. the date and time the medication was administered; B. The dosage; C. The route of administration; F. Any results achieved and when those results were observed if applicable, and G. The signature and title of the person administering the drug. Event ID: Facility ID: 105305 If continuation sheet Page 37 of 37